N444: Test 1

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N444: Test 1 by Mind Map: N444: Test 1

1. Tracheostomies

1.1. Background

1.1.1. Causes of obstruction Disease Bronchoconstriction Foreign body Secretions

1.1.2. Methods of assessment Inspection Palpation Auscultation

1.2. Characteristics

1.2.1. Surgical opening (stoma) Includes indwelling tube Temporary or permanent

1.2.2. Indications Bypass URT obstruction Facilitate removal of secretions Long-term mechanical ventilation Prevent aspiration Replace ET tube

1.2.3. Advantages Less direct laryngeal injury Facilitate oral care Increase mobility & comfort Allow for speech Facilitate oral feedings

1.2.4. Types Cuffed Inflated cuff on tube Reduces aspiration risk Used in mechanical ventilation Uncuffed When client can protect their airway Not paired with mechanical ventilation

1.2.5. Complications Early Bleeding Pneumothorax Air embolism Aspiration SQ or mediastinal emphysema Laryngeal nerve damage Tracheal wall penetration Long-term Accumulation of secretions Cuff protrusion Infection Innominate artery rupture Dysphagia Tracheoesophageal fistula Treacheal ischemia >> necrosis Prevention Warmed humidity Maintain cuff's pressure Auscultate & suction PRN Skin integrity S/S of infection Hydration Sterility

1.3. Tracheostomy care

1.3.1. Components Changing or cleaning inner cannula Changing dressing Inspecting skin Suctioning PRN

1.3.2. Assessment Breath sounds Vital signs Oxygen saturation Coughing ability Visible secretions WOB

1.3.3. Diagnoses Ineffective airway clearance Disturbed body image Risk for aspiration, bleeding, infection Deficient knowledge Anxiety Impaired verbal communication

1.3.4. Care plan On-going assessment Maintaining airway Preventing complications Management Suctioning while maintaining oxygenation Site care Other objectives Alleviate apprehension Provide effective communication

1.4. Suctioning

1.4.1. Indications Coughing Secretions Respiratory distress Decreasing oxygen saturation

1.4.2. Monitoring Hypoxemia HTN Dysrhythmias Decreased oxygen saturation Bronchospasms Atelectasis Increased ICP

1.4.3. Documentation Client's response Vital signs Breath sounds Cardiac rhythm Oxygen saturation Amount & consistency of secretions

1.4.4. Gerontological differences Assess lung sounds before & after Fragile skin during stoma care

1.5. Patient education

1.5.1. Daily care

1.5.2. Emergency measures

1.5.3. Community resources

1.5.4. Home-health nursing

2. IV Medications

2.1. Nurse's role in IVs

2.1.1. Insert peripheral catheter

2.1.2. Monitor site

2.1.3. Administer & maintain therapy Instill fluid into a vein Technically a medication

2.1.4. Know therapeutic action of therapy Replace lost fluid Maintain fluid/electrolyte balance Give IV medications Nutrition Blood products

2.1.5. Assess response to IV

2.2. Appropriate IV sites

2.2.1. Arms & hands

2.2.2. Avoid certain areas Legs/feet Sites distal to infiltration Sclerosed or thrombosed veins Arms wtih shunts/fistula (renal pts) Edema Infection Clots Scarring Skin breakdown Arm on side of mastectomy

2.3. IV catheters

2.3.1. Plastic catheter Flexible Less likely to puncture wall Long-lasting (72 hours) 14-24 gauge 24 - Pediatric/elderly 14 - Cardiac patients or large volume

2.3.2. Needle (butterfly) Shorter Little to no "threading" Less trauma or pain Inflexible Easily punctures wall Increased risk of infiltration

2.4. Central lines

2.4.1. Types PICC Peripherally inserted central catheter Can be inserted by nurse w/special training Chemport Chest Arms Abdomen TLC Subclavian or internal jugular vein By MD only Broviac-Hickman Tunneled vs. non-tunneled catheters

2.4.2. Advantages Less frequent sticking Can give vesicants

2.4.3. Disadvantages Must be placed by MD* High risk for complications

2.5. IV maintenance

2.5.1. Tubing 72-96 hours* Exceptions to rule Changing tubing with new IV site Blood or TPN

2.5.2. Sites 72-96 hours Infiltration Dislodged catheter Pain reported

2.6. Potassium infusions

2.6.1. Never given direct IV push

2.6.2. Infusion pump only

2.6.3. Must be diluted

2.6.4. No faster than 10-20 mEq/hr through peripheral IVs

2.7. Complications of IVs

2.7.1. Infiltration

2.7.2. Phlebitis Pain or burning At catheter site

2.7.3. Thrombus

2.7.4. Site infection

2.7.5. Fluid volume excess SOB Crackles Tachycardia

2.7.6. Bleeding

2.7.7. Sepsis

2.8. Venipuncture

2.8.1. For blood specimens

2.8.2. Slightly greater angle (15-30 degrees)

2.8.3. Specific tubes Lavender CBC Blood typing Red or yellow Chemistries Often the red top** Blue Coags - PT/PTT/INR Green Cardiac enzymes Light or dark blue Additional coags DIC panels FDP

2.8.4. Assessment Type of test ordered Timing or client preparation Ability to cooperate

2.9. Blood cultures

2.9.1. Process Collect 10-15 mL of blood Inoculate anaerobic, then aerobic cultures Mix gently Label and transfer Date/time/initials Site***

2.9.2. Should be negative

2.9.3. Positive = bacteremia

2.9.4. May have false-positive if contaminated

3. Blood & TPN

3.1. Blood

3.1.1. Increased safety

3.1.2. AB (receiver) & O (donor)

3.1.3. Ordered by HCP "Type and screen" "Type and match" "Type, match & hold X units"

3.1.4. Many varieties Whole blood All parts For hemorrhage >20% of circulating volume Restores oxygen-carrying capacity + volume Given over 2-4 hours Packed RBCs No plasma! Same mass of RBCs as whole, but less volume (-250 mL) Decreased risk of overload For restoring oxygen-carrying capacity Given over 2-4 hours Washed RBCs Removed foreign proteins For patients w/anaphylactic reactions Expires after 24 hours Give over 2-4 hours Platelets Donor types Forms

3.1.5. Transfusion Pre-procedure Check orders T&M to lab Explain procedure; get consent Get blood <30 min before transfusion Hang w/i first 30 min Procedure Baseline vital signs May use blood wormer Flush with NS Check the site (18*-20 GA) Give slowly during first 15 min*** Observe for adverse effects Increase rate if all clear Observe per policy Document Never add meds to blood!!!

3.1.6. Central lines Ends in SVC or IVC 10-24 inches long Must verify placement by X-Ray Complications Air embolism Clot or occlusion Infection Hemothorax Pneumothorax Brachial plexus injury Malposition Migration or external damage Management

3.2. TPN

3.2.1. IV infusions of nutrition Pump only Check flow rate q1hr VS q4 I&Os Daily weights Chems q3 days* Have to wean off

3.2.2. Maintain or improve status over long-term

3.2.3. May be given with lipid (fat emulsion) Supplemental kCals Gives good fatty acids Infuse slow! (Over 12 hours!)

3.2.4. Goal is to move towards use of GI tract

3.2.5. Complications Embolism, occlusion, sepsis Electrolyte imbalance Hypercapnia hGLY or HGLY HHNK/coma Pneumothorax Thrombosis

3.2.6. May require CVC (>10% dextrose) Hypertonic Irritating solution

3.2.7. Change q24 Remove from refrigerator 1 hour early Change tubing q12

3.2.8. May hang bag of dextrose if new TPN hasn't arrived Prevents rebound hGLY

4. Older Adults

4.1. Theories of aging

4.1.1. Chronological

4.1.2. Subjectively

4.1.3. Functional

4.1.4. Many, many, others!

4.2. Leading CODs

4.2.1. Heart disease

4.2.2. Malignant neoplasms

4.2.3. Cerebrovascular diseases

4.2.4. COPDs

4.2.5. Alzheimer's

4.2.6. Diabetes

4.2.7. Pneumonia/influenza

4.2.8. Kidney-related disorders

4.2.9. Accidents

4.2.10. Sepsis

4.3. Health promotion

4.3.1. Cholesterol

4.3.2. Colonoscopy

4.3.3. Fasting blood glucose

4.3.4. Fecal occult blood

4.3.5. Pap smear

4.3.6. PSA

4.3.7. Mammogram

4.3.8. ASA prophylaxis

4.3.9. AAA screen (65+)

4.3.10. Vaccinations Herpes zoster @ 60 yo Influenza Pneumococcal @ 65 yo TDAP booster q. 10yrs

4.4. Age-related changes

4.4.1. Cardiovascular Decreased CO Poor stress response Too consistent HR and SV Slower recovery Increased BP

4.4.2. Respiratory Increased RLV Decreased muscle strength Decreased endurance Decreased vital capacity Decreased gas exchange/diffusing Poor cough efficiency

4.4.3. Integumentary Decreased protective substances Decreased glandular activity Capillary fragility

4.4.4. Musculoskeletal Loss of bone density, muscle strength/size Degenerated joint cartilage

4.4.5. Gastrointestinal Decreased senses Decreased salivation Dysphagia Delayed emptying Reduced motility

4.4.6. Nervous Reduced speed of conduction Increased confusion w/illness Loss of environmental cues Reduced cerebral circulation (syncope)

4.4.7. GU & Reproductive Slower response Female differences Vaginal narrowing Decreased elasticity Decreased secretions Relaxed perineal muscles Detrusor instability Urethral dysfunction Male differences Less firm testes Decreased sperm production BPH

4.5. Pharmacological changes

4.5.1. Polypharmacy

4.5.2. Altered response to drugs

4.5.3. "Start low, go slow"

4.5.4. Noncompliance

4.6. Mental health issues

4.6.1. Depression (most common)

4.6.2. Delirium (acute) Disorientation >> Altered LOC, brain damage >> Death

4.6.3. Dementia Decline in reasoning Reduced ability to perform ADLs

4.7. Nursing care for elders

4.7.1. Cognitive function

4.7.2. Safety

4.7.3. Independence

4.7.4. Good mood

4.7.5. Communication

4.7.6. Intimacy

4.7.7. Nutrition/Activity/Rest

4.7.8. Home care

4.8. Geriatric syndromes

4.8.1. Altered mobility

4.8.2. Dizziness/falls

4.8.3. Urinary incontinence

4.8.4. Susceptibility to infection

4.8.5. Altered pain/fever responses

4.8.6. Altered emotional impact

4.8.7. Altered systemic responses

4.9. "Atypical presentations"

4.9.1. 3 types Vague presentation Altered presentation Non-presentation

4.9.2. Often signaled by behavioral change

4.9.3. Other presentations Failure to eat/drink Failure to develop a fever r/t increased WBCs Lack of appropriate pain response

4.9.4. At-risk groups 85+ yo Many comorbidities/meds Cognitive/functional impairment

4.9.5. Best screening Comprehensive, but problem-focused Focused physical exam Does an ATP exist??

4.10. Elder neglect/abuse

4.10.1. Neglect** Caregiver strain?

4.10.2. Physical

4.10.3. Emotional

4.10.4. Sexual

4.10.5. Financial

5. Chronic Disease

5.1. Characteristics

5.1.1. Over phases

5.1.2. Adaptation

5.1.3. Adherence!

5.1.4. Leads to more disorders

5.1.5. Entire family affected

5.1.6. Collaboration required

5.2. Management

5.2.1. Prevention first!

5.2.2. Then, manage S/S

5.2.3. Avoid complications, acute Sx

5.2.4. Health promotion

5.2.5. Functionality

5.3. Nursing care

5.4. Diabetes in elderly

5.4.1. 15-20% of 65+ yo

5.4.2. Very common

5.4.3. More prevalent in non-whites

5.4.4. Reduces life-expectancy by 10 yo

5.4.5. Doubled mortality rate & risk of complications

5.4.6. Increased risk of geriatric syndromes

5.5. Disabilities

5.5.1. Impairment that seriously limits 1+ major life activities

5.5.2. Remember, "people first"!

5.5.3. Types of disabilities Developmental Acquired Age-related

5.5.4. Models of disability Medical Rehab Biopsychosocial Interface

5.6. Chronic Pain

5.6.1. Over 3 or more months

5.6.2. Suffering + sleepless + sad

5.6.3. Similar treatment r/t acute pain Prevention/management of ADRs Enhance QOL Realistic goals

5.7. Rehabilitation

5.7.1. Comprehensive

5.7.2. Long-term

5.7.3. Multidisciplinary

5.7.4. Can use FIMTM tool for functional assessment